To reduce your liver cancer risk, prevent liver disease — and cirrhosis

By Nicole Brudos Ferrara

Most people who have cancer in the liver have cancer that has spread (metastasized) from another location, such as the colon, stomach or breast. This is different from the most common type of primary liver cancer, called hepatocellular carcinoma, which starts in liver cells called hepatocytes. More than 41,000 new cases of hepatocellular carcinoma will be diagnosed in 2023.

Hepatocellular carcinoma occurs most often in people with underlying liver disease. "Having liver disease puts you at risk for cirrhosis — scarring of the liver. It's cirrhosis that predominantly puts you at risk for the development of liver cancer," says Denise Harnois, D.O., a Mayo Clinic transplant hepatologist.

Dr. Harnois explains what cirrhosis is, how it leads to liver cancer, and what you can do to prevent it:

What is cirrhosis, and how does it cause cancer?

When excessive alcohol consumption, infection or another cause injures the liver, it tries to repair itself. This causes scar tissue to form. Over time, as more liver cells are damaged and repaired, some develop changes (mutations) in their DNA that cause them to grow out of control and form a tumor.

"Researchers think cirrhosis creates an environment in the liver that puts you at risk for the development of liver cancer," says Dr. Harnois. "If you have one liver cancer, even if you treat that cancer successfully, you remain at an increased risk of developing it again. More than 50% of people diagnosed with liver cancer will get another lesion within two to five years. Unless you replace the liver through transplant, the liver still provides a kind of fertile ground for the development of new cancers."

What causes cirrhosis?

Cirrhosis can develop in the liver for many reasons. Until recently, in the U.S. and many other parts of the world, the cause was often viral hepatitis. Chronic infection with the hepatitis B virus (HBV) or hepatitis C virus (HCV) increases your risk of liver cancer.

"We developed direct-acting antiviral medications, and so many people have had their hepatitis C treated," says Dr. Harnois. "But it's possible they had advanced fibrosis (a buildup of scar tissue) at the time of treatment and remain at risk of developing liver cancer."

An accumulation of fat in the liver can also cause cirrhosis. Dr. Harnois says this has two causes: alcohol and nonalcoholic fatty liver disease (NAFLD), also known as metabolic dysfunction-associated steatotic liver disease (MASLD). Drinking an excessive amount of alcohol daily over many years can lead to cirrhosis. NAFLD affects people who drink little to no alcohol.

"NAFLD is more common in people carrying extra weight, especially in the midsection, and in people with diabetes and hyperlipidemia (high cholesterol)," says Dr. Harnois. "Alcohol-related liver disease and NAFLD have now become the top causes of chronic liver disease in the U.S. and most of the developed Western world. It's the No. 1 reason people need to consider liver transplants and are starting to be at risk for liver cancer."

Who is most at risk of developing liver cancer?

Dr. Harnois says some subgroups of people who have chronic liver disease and cirrhosis are at higher risk of developing liver cancer than others. "The highest risk population for the development of hepatocellular carcinoma is men versus women. And we don't understand that difference," she says. "But men with cirrhosis are much more likely than women to develop liver cancer."

People with hepatitis B also have a higher risk of developing liver cancer at a much earlier age — without necessarily developing cirrhosis. "Those patients will be at risk when they've acquired hepatitis B early in life, either from mother to child or very early in childhood," says Dr. Harnois. "That's why the hepatitis B vaccinations have been so important — they have dramatically reduced the risk of liver cancer in populations most at risk for early acquisition of hepatitis B."

Dr. Harnois says people of Hispanic descent seem to be at the highest risk for the progression of NAFLD to liver cancer. And liver specialists are now seeing liver cancer develop in people without cirrhosis. "We're starting to see some increased risk of liver cancer even without advanced fibrosis or cirrhosis in patients with NAFLD. We don't fully understand that because it's new."

Preventing liver disease and cirrhosis

"It's the cirrhosis that puts you at risk. If you prevent the development of liver disease, or if you develop some evidence of liver disease and you don't let it progress to the point where it causes cirrhosis — that's the first piece of prevention," says Dr. Harnois.

Here's what you can do to prevent liver disease and cirrhosis:

• If you drink alcohol, do so in moderation. For women, this means no more than one drink a day. For men, this means no more than two drinks a day.
• Maintain a healthy weight to prevent diabetes and NAFLD. Eat a healthy diet and exercise most days of the week. If you need to lose weight, reduce the calories you eat each day and increase your exercise. "Having high cholesterol and triglycerides and high blood sugars and carrying too much weight puts you at risk for liver disease, cirrhosis and liver cancer. We know that even if you're showing some evidence of scarring, you can reverse that by controlling blood sugar, cholesterol and weight loss. You can prevent the progression of liver disease and liver cancer," says Dr. Harnois.
• Get vaccinated against hepatitis B. Almost anyone can get the hepatitis B vaccine, including infants, older adults and those with compromised immune systems.
• Take measures to prevent hepatitis C. There is no vaccine for hepatitis C, but you can reduce your risk of infection by practicing safe sex, not using IV drugs, and only getting piercings and tattoos at shops that properly sterilize needles.
• If you have hepatitis B or C, seek treatment. If you're 18 years of age or older, Dr. Harnois recommends getting tested for hepatitis. Treatments are available for hepatitis b and hepatitis C infections, and research shows that treatment can reduce the risk of liver cancer. "Treating hepatitis C substantially reduces your risk of liver cancer and reduces your risk of developing cirrhosis. But even if you have cirrhosis, if you treat hepatitis C, it will reduce your risk of liver cancer," she says.
• Know your family medical history. Certain inherited liver diseases can increase the risk of liver cancer, including hemochromatosis and Wilson's disease. "These diseases can put you at risk for developing cirrhosis and liver cancer. Talk to your healthcare professional about testing and treatment if you have family members with these conditions," says Dr. Harnois.

What if you already have cirrhosis?

"Having a diagnosis of cirrhosis doesn't automatically mean that you're going to develop liver cancer. It means that you must take preventive measures," says Dr. Harnois.

That means advocating for the care you need to prevent liver cancer or catch it early. "You'll need an upper endoscopy to make sure you don't have enlarged veins in the esophagus that can cause problems with bleeding," says Dr. Harnois. "You'll need to avoid using alcohol and exposing yourself to other things that make your liver work harder and make you more likely to develop complications from scarring."

Most importantly, it means screening every six months with imaging and a blood test that measures the alpha-fetoprotein (a tumor marker) in your blood.

Only 22% of people with cirrhosis and a high risk for liver cancer get screened, says Dr. Harnois. "In some circumstances, these are patients who have been treated for hepatitis C, and once treatment is finished, they don't think about the fact that they have cirrhosis because they haven't had complications from their liver disease. But they remain at risk, and they need to be screened every six months for liver cancer."

If you have cirrhosis, talk to a healthcare professional about a plan to reduce your risk of developing liver cancer or to catch it early.

Catching liver cancer early

For the general population, screening for liver cancer hasn't been proven to reduce the risk of dying of liver cancer, and it isn't generally recommended. If you have advanced fibrosis or liver cirrhosis, Dr. Harnois says you should discuss the pros and cons of screening with your healthcare professional. "People with hepatitis B are typically screened at age 40 if they're male and at age 50 if they're female," she says. If you immigrated from a region of the world such as Sub-Saharan Africa where hepatitis B infection is chronic and you acquired your hepatitis B at birth or in early childhood, you may need to be screened earlier because you are at increased risk of liver cancer.

As with all cancers, treatment is most effective when the cancer is found early. "We know that if you screen these patients twice a year with an imaging study — an ultrasound, MRI or CT — and an alpha-fetoprotein blood test, you typically find cancer early," says Dr. Harnois.

Dr. Harnois wants people with liver disease and cirrhosis to know that if they do develop liver cancer, there are options for treatment. "Often, I see patients who are terrified because they've been given a liver cancer diagnosis, but they haven't been given an understanding of the potential options — not just for treatment, but for cure."

Learn more

Learn more about cirrhosis and liver cancer and find a liver cancer clinical trial.

Join Mayo Clinic Connect, an online community for patients and caregivers.

Also, read these articles:

• "Mayo Clinic Minute: "ABCs of hepatitis"
• "Living in the moment: Susan Parrott"
• "Researchers hope to eliminate hepatitis, a common risk factor for liver cancer"
• "Treating and preventing liver cancer"
• "Targeted radiation therapy: Y-90 and liver cancer"
• "Why more liver donors are needed"